Is stab phlebectomy of the right anterior accessory saphenous vein (R AASV) thigh medically necessary for a female patient with symptomatic varicose veins of the right lower extremity with pain?

Stab Phlebectomy of R AASV Thigh is NOT Medically Necessary Without Concurrent or Prior Saphenous Vein Ablation

The request for stab phlebectomy of the R AASV thigh does NOT meet medical necessity criteria because the MCG guideline explicitly requires that phlebectomy be "performed concurrently with or after saphenous vein stripping or ablation," and no ablation or stripping has been performed or ordered for this patient. 1, 2

Critical Missing Requirement

The MCG criteria A-0735 clearly states that stab phlebectomy requires treatment of saphenofemoral junction reflux to be performed concurrently or previously. 1 This is not simply a preference—it is a mandatory criterion based on evidence showing that:

• Untreated junctional reflux causes persistent downstream pressure, leading to tributary vein recurrence rates of 20-28% at 5 years even after successful phlebectomy. 1
• Multiple studies demonstrate that treating junctional reflux with procedures such as radiofrequency ablation or stripping is essential to reduce varicose vein recurrence when performing phlebectomy. 2
• Chemical sclerotherapy or phlebectomy alone has inferior long-term outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation or surgery of the main truncal veins. 1

Why This Criterion Exists

The American College of Radiology explicitly states that if a patient has incompetence at the saphenofemoral junction, the junctional reflux must be treated concurrently to meet medical necessity criteria for phlebectomy. 2 The clinical rationale is straightforward:

• The R AASV shows 3.8mm diameter at the proximal thigh with 2478ms reflux—this represents significant junctional reflux that will continue to drive downstream varicosity recurrence. 1
• Treating only the tributary veins (via phlebectomy) without addressing the source of reflux at the junction results in predictably poor long-term outcomes. 1, 2

Evidence-Based Treatment Algorithm

Step 1: Address Junctional Reflux First

The patient requires endovenous thermal ablation of the R AASV proximal segment (at the junction where it is 3.8mm) as the primary procedure. 1, 3 This meets criteria because:

• Vein diameter of 3.8mm exceeds the 2.5mm minimum threshold for foam sclerotherapy/ablation. 1
• Reflux time of 2478ms far exceeds the 500ms threshold for pathologic reflux. 1, 3
• The patient has completed >3 months conservative management. 1, 2
• Symptomatic presentation (burning pain) causing functional impairment meets symptom criteria. 1, 3

Step 2: Phlebectomy as Adjunctive Treatment

Once the junctional reflux is treated with ablation, stab phlebectomy of the distal AASV segments (described as "too small for ablation in the mid thigh and at the knee") becomes medically necessary as an adjunctive procedure. 1, 2 This can be performed:

• Concurrently during the same operative session as the ablation. 1, 2
• As a staged procedure after ablation, if symptoms persist from the smaller tributary segments. 1

Specific Recommendation for This Case

Deny the standalone phlebectomy request and recommend the following treatment plan:

1. Primary procedure: Endovenous thermal ablation (radiofrequency or laser) or foam sclerotherapy of the R AASV proximal thigh segment at the junction (3.8mm diameter, 2478ms reflux). 1, 3

2. Adjunctive procedure: Stab phlebectomy of the R AASV mid-thigh and knee segments (described as too small for ablation) performed concurrently with the ablation. 1, 2

This combined approach:

• Meets all MCG A-0735 criteria. 1, 2
• Addresses the underlying pathophysiology by treating junctional reflux. 1, 3
• Provides comprehensive treatment with 91-100% occlusion rates for ablation and appropriate tributary removal. 1, 3
• Minimizes recurrence risk compared to phlebectomy alone. 1, 2

Technical Considerations

• The 3.8mm diameter at the AASV junction is adequate for foam sclerotherapy (Varithena), which requires ≥2.5mm diameter and achieves 72-89% occlusion rates at 1 year. 1
• Alternatively, if the vein straightens sufficiently with tumescent anesthesia, radiofrequency ablation could be considered, though foam sclerotherapy may be more appropriate for this diameter. 1, 3
• The smaller distal segments are ideal candidates for stab phlebectomy, which is specifically designed for tributary veins and provides excellent cosmetic results through 1-3mm incisions. 4, 5

Common Pitfall to Avoid

Do not approve phlebectomy as a standalone procedure for this patient. The provider's note stating "can schedule for phleb if conservative therapy does not relieve her discomfort" reflects a misunderstanding of evidence-based treatment sequencing. 1, 2 Phlebectomy without treating the 2478ms junctional reflux will result in predictable recurrence and represents suboptimal care. 1